Breast Reconstruction

Aesthetic & Reconstructive Surgical

Associates, LLC Jaime Ivan Flores, M.D.

Stuart, Devon (2009). Johns Hopkins Medicine.

RECONSTRUCTION GOALS

Shape Symmetry

Size Soft

Sensual Natural

Stuart, Devon (2009). Johns Hopkins Medicine.

Mastectomy with No Reconstruction

The ill patient

Advanced tumor

Patient choice

Bilateral Unilateral

Alternatives: Breast Prostheses Fitted with

Post-Mastectomy Brassieres

JHH has Image Recovery Center to assist with fittings for patients with no reconstruction and those with

asymmetry during staged reconstruction. Insurance generally covers cost.

Stuart, Devon (2009).

Johns Hopkins

Medicine.

Reconstructive

Options

Autologous Tissue (Your own tissue)

Combination

Implant

Options: •Abdominal tissue

•Buttock tissue •Back tissue

•Inner thigh tissue

Options: •Temporary

Tissue Expander •Saline

•Silicone gel

•Autologous tissue +

Implant for increased projection

Immediate, Staged, or Delayed

Reconstruction Reasons for

Immediate

Reasons for

Staged

Reasons for

Delayed

• Prophylactic or early

stage cancer (no

radiation)

• Possible radiation • Metastatic or

inflammatory breast

cancer

• Schedule permits date

in near future

• Other medical issues

complicating longer

procedure

• Other medical issues

complicating

immediate

reconstruction

• Relative indication:

May have better results

if patient has large or

drooping breasts or

breast asymmetry

• Patient choice

Implant

Tissue Expander

Single Stage Implant

Replacement With

Permanent Implant

Satisfactory Result ?

No

Expansion in office Until desired size achieved

•High rate of revisions •Limited in size and shape •Must have skin-sparing

and better w/nipple-sparing mastectomy

Expander -> Implant

Expansions: In clinic weekly (at most)

Usually stop during chemotherapy

Always stop during radiation

Generally not painful, may have 1-2 days muscle soreness

Stuart, Devon (2009). Johns Hopkins Medicine.

Functions:

•Expand muscle and skin

•Create a pocket for eventual implant or flap

•Preserve lower fold of breast

Tissue Expanders

Stuart, Devon (2009 ).Johns Hopkins Medicine.

• One night inpatient hospital stay

• At least one drain per breast

(removed 1-2 weeks on average)

• Most able to return to work in 2-4 weeks

What to Expect

Initial mastectomy

w/expander or implant

Stuart, Devon (2009). Johns Hopkins Medicine.

Tissue Regeneration Matrix Acellular dermal collagen

matrix (i.e. Alloderm, Surgimend, Veritas)

Blood vessels grow into over time

“Internal bra” or sling

Preserves fold under breast

Complications (i.e. infection), but cannot be rejected

Stuart, Devon (2009). Johns Hopkins Medicine.

What tissue expanders may look like right after surgery

Amount of fluid in expanders at time of

surgery depends on blood flow to the skin

Larger amount possible with good blood flow

Staged Implant Reconstruction Good Candidates:

-No history of chest wall radiation

-Will not undergo radiation therapy

-Thin patients

Before mastectomy

1st Stage: Mastectomy with Tissue Expanders

Final Implants and Nipple Reconstruction (without

areolar tattoo)

Staged Implant Reconstruction with Intermediate Tissue

Expanders

Prior to Mastectomy Prior to Mastectomy

After Implant Exchange And Healed Nipple Reconstruction

Final Result After Tattooing

After Implant Reconstruction

Prior to Mastectomy

Post-Mastectomy with Single Stage Implants

Staged Bilateral Implant Reconstruction

Better candidates are small-breasted, with skin and nipple-sparing mastectomies

as seen here *High rate of revisions

Left tissue expander followed by implant

reconstruction

Staged Unilateral Implant Reconstruction

Tissue Expander (slightly inflated during initial placement)

Right Implant and Left Breast Lift

Advantages of Implants:

• Quicker reconstruction process

• Shorter outpatient surgeries

• Faster recovery

• No scarring of other areas of body

Disadvantages of Implants:

• Implants may need replacement (approx.

10% will rupture in 9 yrs)

• Under chest muscle,

can cause some tightness/discomfort

• Less natural-feeling

Ultimately patient’s preference, but with

radiation, autologous has better outcome

Previous Mastectomy with No Reconstruction

Delayed Placement of Tissue Expander

Final Implant Reconstruction with Right Side Breast Reduction

Delayed Implant Reconstruction with Tissue

Expanders

Potential Implant Complications

Following Radiation Therapy

Unacceptable cosmetic outcome (high-riding, firm) Pain/tightness Capsular contracture Slowed healing Infection Exposure of implant through the skin

Complications with implants & radiation:

LIFELONG RISKS

Potential Implant Complications Following

Radiation Therapy

Left Implant After Nipple-Sparing Mastectomy & Radiation,

Right Breast Augmentation

Tissue expanders followed by implants after left side radiation

Pedicled Latissimus Dorsi Flap

• Done less frequently, uses back muscle

• T-dap uses back skin and fat, spares back muscle, but not enough tissue to reconstruct entire breast

• Both often require an implant for increased projection

Healed Back Scar

Healed Lat Flap w/Implant for Increased Projection

©2009 Copyrighted Johns Hopkins Medicine

DIEP Flap

• Skin, fat, and

blood vessels

taken from

lower portion

of abdomen

• Vessels

connected

under

microscope to

chest vessels

• Hip to hip

scar on

abdomen,

around belly

button, & scar

around

abdominal skin

flap on breast

• Surgery length varies

(Generally 4-6+ hrs per side)

• Hospital stay 3 nights

• Drains in each side of abdomen and in the breast

• Return to work approx. 4-6 weeks

Stuart, Devon (2009). Johns Hopkins Medicine.

Recipient Vessels in Chest Generally Internal Mammary Artery & Vein (IMA/IMV)

Accessed through rib resection

(removal of small piece of cartilage from end of rib)

Stuart, Devon (2009).Johns Hopkins Medicine.

Mapping Abdominal Perforator

Vessels with 3D CT Scan

Stuart, Devon (2009). Johns Hopkins Medicine.

Sensate Breast Reconstruction

During unilateral autologous breast

reconstruction, this is attempted if nerves can be found in abdomen and chest

Reconnected using nerve tube

Hope to gain some sensation of skin and chest wall, but will never regenerate full

sensation/nipple sensation

Staged Bilateral DIEP Flaps

Tissue Expanders (left side radiation)

Unilateral DIEP flap

Results similar to a “tummy tuck”

Abdominal scar often hidden by most underwear/clothing

Bilateral DIEP flap Unilateral DIEP flap

Prior to mastectomy

Tissue Expander after radiation

Left DIEP flap

Right breast lift to match

Completed DIEP Flaps w/Nipple

Reconstruction and Tattoo

Healed Flap After 2 Years

*Nipple reconstruction is patient’s preference

SGAP Flap

Stuart, Devon (2009).Johns Hopkins Medicine.

1st Stage: Tissue Expanders

Lateral SGAP (L-SGAP)

Flap taken from more lateral position of the buttock

Results in shorter, more lateral scar

Bilateral SGAP with skin paddles excised

Lateral SGAP (L-SGAP)

Flap is taken from more lateral (side) area of buttock, creating shorter scar

Unilateral SGAP

Delayed Bilateral SGAP

Markings made prior to surgery

to map blood vessels

Revisions to buttock may include fat grafting and/or liposuction of the opposite side for symmetry

SGAP

Oncoplastic Breast Reduction Breast Reduction at the Time of Lumpectomy

Good candidates are those who are eligible for breast conservation with lumpectomy and have

larger breasts or desire a breast reduction

Oncoplastic Breast Reduction

Complications

Autologous

Flap Loss Risk=1-3%

(L-SGAP, S-GAP, DIEP)

Implant

Unacceptable result With implants (contracture,

radiation, infection, exposure)

COMPLICATIONS

Healthy flap (warm, pink)

Failing Flap (cool, pale)

* Most likely to fail within 24-48 hours WHILE IN HOSPITAL

Reason for Failure:

Blood not properly flowing in and/or out of blood vessels to the flap

* Can sometimes correct medically or surgically

Otherwise, must remove flap and consider other options

Methods to Attempt to Save a Failing Flap

Surgical: Explore vessels for clot, kink, hematoma, etc.

Medical : Aspirin (blocks platelets) Heparin (blood thinner) Viagra (dilates blood vessels) Leech therapy (secretes blood thinners)

Right DIEP Flap and Left Implant (after failed left DIEP flap)

Necrosis of Mastectomy Skin

Healed, following operation to remove dead skin

Failed Left Reconstruction

Pedicled Latissimus Flap +

Implant

Left Lat Flap + Implant Right Reduction

Scarring

Everyone scars differently. Some people develop keloid or hypertrophic scarring as

seen here.

Anticipate Asymmetry Normal side can be adjusted to match

reconstructed breast

Opposite Breast

Reduction Opposite Breast

Lift Opposite Breast

Augmentation Opposite Breast

Lift + Augmentation

Options: Saline or Silicone

Gel Implant

Stages of Breast Development

Ptosis= “sagging” of breast Stuart, Devon (2009).Johns Hopkins Medicine .

Bilateral Immediate DIEP Flap

Although things may not look

cosmetically pleasing initially…

The end result is greatly improved

With time and small outpatient

revision surgeries…

Bilateral DIEP

Flaps

With slight asymmetries

that can be improved

upon

Breast Mound Reconstruction Complete

Nipple Reconstruction

(outpatient surgery approx. 1 hr or less)

Acceptable Symmetry ?

Yes No

Lift/Reduction/Augmentation for

normal side

+ Nipple Reconstruction

(outpatient surgery

approx. 2-3 hrs)

Color Tattoo of areola

6-8 weeks later

Revisions

Revisions may include liposuction, direct excision,

and/or fat-grafting to improve symmetry

Nipple Reconstruction

Reconstructed from tissue of the same area

Made larger initially as they flatten dramatically over first few months

The color can be tattooed 6-8 weeks following nipple reconstruction

Breast Reduction Removes excess skin and breast

tissue

Stuart, Devon (2009).Johns Hopkins Medicine.

Breast Reduction as Matching

Procedure

Breast Reduction as Matching

Procedure

Breast Lift Removes excess skin from breast

envelope, no breast tissue removed

Stuart, Devon (2009). Johns Hopkins Medicine.

Breast Lift

Breast Lift

Breast Augmentation

Stuart, Devon (2009).Johns Hopkins Medicine.

Left breast implant reconstruction with right

breast augmentation matching procedure

Summary of Options Prosthetic/Implant-Based

Tissue Expander

Saline or Silicone Implant

Autologous Tissue

Free DIEP/SIEA

Free S-GAP

Free L-SGAP

Free TUG

T-Dap

Pedicled Lat Dorsi

Free TRAM

Pedicled TRAM

Other

Flap + Implant

Oncoplastic Breast Reduction

* Remember, breast reconstruction is a

work in progress over time.

With your patience, we strive for natural

results with symmetry in shape and size.